Date of Graduation

Summer 8-2-2023

Document Access

Project/Capstone - Global access

Degree Name

Master of Science in Nursing (MSN)


School of Nursing and Health Professions


Kaiser cohort MSN capstone

First Advisor

David Ainsworth


Background: The setting of this project took place in a small 100-bed community hospital that is a part of a larger healthcare organization in Northern California. The focus of the project was the implementation of standardized education for patients with congestive heart failure (CHF) to lead to an outcome of decreased readmissions. Readmissions to hospitals are costly and effective discharge planning can impact and decrease readmissions.

Problem: The facility in which this project took place has 35 readmissions a year for CHF. It is the third highest DRG and reason for readmissions in 2022. Although there is work in place to decrease readmissions, there is currently not and evidenced-based practice (EBP) utilizing standardized disease specific teaching as a part of the discharge planning and process.

Interventions: The goal of implementing standardized CHF education for all patients in the hospital is to improve the patient understanding of their disease, medications, treatments, tests, diet, and resources available to adequately manage their chronic illness and prevent readmission to the hospital.

Outcome Measures: The outcome measure for this project was to achieve a decrease of 50% reduction of CHF readmissions using a standardized education tool for all patients aged 65 and older in the hospital with a CHF diagnosis regardless of their admitting diagnosis. The first process measure was aimed at a 90% rate of identification of patients with a CHF diagnosis regardless of admitting diagnosis. The second process measure was focused on a goal of 75% rate of completing a CHF care plan in the electronic medical record (EMR) to track education provided.

Results: A total of 232 patients were admitted to the hospital with CHF between March 1 and May 31, 2023. Of these patients 90.5% of them were identified as having CHF on their problem list regardless of admitting diagnosis, and 80% of them had a CHF specific care plan started and documented on in the EMR. Of these 232 patients only 5 patients were readmitted in the 90-day period post implementation resulting in an average of 1.67 readmissions per month, which was a 45% reduction in readmissions.

Conclusion: The implementation of a standardized education tool and development of a process to identify patients with a CHF diagnosis regardless of their admission diagnosis provided consistent disease specific discharge planning resulting in a reduction in readmissions.

Included in

Nursing Commons